Qualitative study of perinatal care experiences among Somali women and local health care professionals in Norway

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Abstract

Objective: To explore how perinatal care practice may influence labor outcomes among circumcised women. Study design: In-depth interviews were conducted with 23 Somali immigrants and 36 Norwegian health care professionals about their experiences from antenatal care, delivery and the management of circumcision. Results: Circumcision was not recognized as an important delivery issue among Norwegian health care professionals and generally the topic was not addressed antenatally. The Somalis feared lack of experience and sub-optimal treatment at delivery. All of the women expressed a strong fear of cesarean section. Health care professionals were uncertain about delivery procedures for infibulated women and occasionally cesarean sections were performed in place of defibulation. Conclusion: We hypothesize that neglect of circumcision may lead to adverse birth outcomes including unnecessary cesarean sections, prolonged second stage of labor and low Apgar scores. We suggest that infibulated women need a carefully planned delivery, correctly performed defibulation and adequate pain relief.

Introduction

Female circumcision is an ancient tradition widely practiced in Somalia and in other parts of Africa. Nearly 100% of women of Somali origin have been circumcised. About 80% have undergone infibulation, which is the most extensive form of circumcision [1], [2]. Infibulation leaves a pinhole introitus of about 1 cm in diameter. The vulva is closed by a seal of varying thickness created after adaptation of labia majores [3]. As a result of the migration of Somali women to Europe during the past 10 years Norwegian doctors and midwives have encountered an increasing number of infibulated women. Since 1998, there have annually been more than 300 births in Norway to women of Somali origin. Available studies and practical experience indicate that women of Somali origin represent a high-risk group in obstetrics. The risk of intrauterine fetal distress, emergency caesarean sections, low Apgar scores and intrauterine death among women of Somali origin is approximately three times greater than among ethnic Norwegians. However, the risk intrapartum and neonatal death was not significantly increased [4], [5].

It has been reported that circumcision gives rise to a number of obstetric sequelae, and the number and severity of complications increases with the severity of cutting [2], [6], [7], [8]. Antenatal opening of the seal of infibulation (defibulation) is considered essential for the course and outcome of labor [9]. Are health care professionals adequately prepared to handle deliveries of Somali immigrant women, or do we leave the care for these women to chance and improvisation [10], [11]?

Previous epidemiological studies have provided limited knowledge and we believe that a qualitative approach is appropriate to add knowledge on these issues. By means of qualitative data, we studied ethnic Somali’s and local health care professional’s experiences from antenatal care and delivery. Our intention was to generate hypotheses about how care in pregnancy and birth may influence on the perinatal outcome among ethnic Somalis.

Section snippets

Study population

The Somali participants were recruited for the interviews at meetings through the Somali’s association and in health facilities. A snowball sampling technique was used in which women who had agreed to be interviewed referred the interviewer to other women they knew [12]. The inclusion criteria were born in Somalia and now living in Oslo or the near by region, had gone through female circumcision and had childbirth experience from Norway. Initially, 29 women were willing to be interviewed. Three

Routines of care

In the first interview period none of the perinatal units had established routines for the management of circumcised women and the circumcision status was seldom noted in the records. Information on the defibulation procedure and stitching was also missing. During the second period one of the hospitals had established such routines, and was working to improve them. The outpatient clinics had also discussed the issue and decided to routinely record the circumcision status in the medical records.

Strength and weaknesses of the study

We have chosen a qualitative method to deepen the insight into perinatal care provided to circumcised women. To what extent are the results of this study relevant for the background population? Even though generalizing is not the purpose in qualitative research, the existence of phenomena may be generalized in such research. Our sample was relatively large and heterogeneous with respect to age, parity, education level and origin in Somalia. This gives a higher potential for generalizations so

Acknowledgements

We wish to express our gratitude to the Norwegian Foundation for Health and Rehabilitation and the Norwegian Women’s Public Health Association for funding this study.

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